No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Abdominal Brain and Enteric Nervous System
Abstract
Conventional medical treatment for neurologic disorders such as epilepsy, migraine, and autism focuses on the brain. Although standard medical treatment is often helpful, the underlying causes of these disorders are not well understood. Furthermore, some individuals respond poorly or not at all to regular medicine. Evidence is accumulating in the medical literature that the enteric nervous system (ENS)-that part of the nervous system associated with the alimentary canal-also plays a role in these disorders. Historically, the concept of an autonomous abdominal nervous system was advocated by Byron Robinson, Johannis Langley, and Edgar Cayce. The work of these three prominent historical figures is considered along with modem view-points on the abdominal nervous system. Complementary therapies that address the nervous system of the abdomen have potential as useful adjuncts to conventional treatment for certain neurologic disorders.
... It is not surprising that there are reflexes from the colon that affect the entire nervous system, given the importance of the "abdominal brain" or enteric nervous system (McMillin et al., 1999). It is estimated that 80% of vagal fibers are visceral afferents (Davenport, 1978). ...
... The enteric nervous system has become an active area in physiological research with over 600 articles on Medline since 1985. Modern medicine recognizes abdominal nervous system involvement in several neurological disorders, including migraine, epilepsy, and autism (McMillin et al., 1999). ...
It is well established that the intestine is an important site responsible for the local immune system. It is speculated that people suffering from constipation and carrying fecal residues in the intestine may have a decreased function of this immune system. In this study, colon irrigation, which is cleansing of the colon using a simple hydrotherapy instrument, was performed in 10 subjects with or without the disease. The number of leukocytes and their demarcation were then evaluated. The number and ratio of lymphocytes increased significantly after irrigation. This result suggested that colon irrigation might induce lymphocyte transmigration from gut-associated lymphatic tissues into the circulation, which may improve colon and immune system function.
... It is not surprising that there are reflexes from the colon that affect the entire nervous system, given the importance of the "abdominal brain" or enteric nervous system (McMillin et al., 1999). It is estimated that 80% of vagal fibers are visceral afferents (Davenport, 1978). ...
... The enteric nervous system has become an active area in physiological research with over 600 articles on Medline since 1985. Modern medicine recognizes abdominal nervous system involvement in several neurological disorders, including migraine, epilepsy, and autism (McMillin et al., 1999). ...
Colonic irrigations enjoy widespread popularity among alternative medicine practitioners, although they are viewed with considerable skepticism by the conventional medical community. Although proponents make claims of substantial health benefits, skeptics cite the lack of evidence for health benefits and emphasize the potential for adverse effects. Yet historically, there are clinical reports of effectiveness and virtually no research refuting these reports. Instead there was a campaign against exaggerated claims by nonmedical practitioners that resulted in a movement away from this form of therapy without any scientific study of efficacy. Given the current popularity of colonic irrigations, it is important that such research be performed, which will require a quantitative estimate of the potential for adverse effects. Although there is little specific literature on colonic irrigations, a review of the literature on related procedures such as enemas and sigmoidoscopies suggests that the risk of serious adverse effects is very low when the irrigations are performed by trained personnel using appropriate equipment.
... An alternative and so far not (or only insufficiently) investigated stimulation of the vagus nerve could be performed manually viscero-osteopathically on the abdomen (voVNS). Because of the high (approximately 75%) afferent fiber content of the vagus nerve, viscero-sensory information from the abdomen and thorax can be expected to exert more influence on the brain than vice versa (McMillin et al., 1999;Critchley and Harrison, 2013;Cerritelli et al., 2021). Also, the development of the primordial intestine, which precedes the development of the neural tube in time, underscores this directionality which supports the concept of a body-vagal-brain axis as part of the human physiolome Ivanov, 2021). ...
Non-invasive transcutaneous vagus nerve stimulation elicits similar therapeutic effects as invasive vagus nerve stimulation, offering a potential treatment alternative for a wide range of diseases, including epilepsy. Here, we present a novel, non-invasive stimulation of the vagus nerve, which is performed manually
viscero-osteopathically on the abdomen (voVNS). We explore the impact of shortterm voVNS on various local and global characteristics of EEG-derived, large-scale evolving functional brain networks from a group of 20 subjects with and without epilepsy. We observe differential voVNS-mediated alterations of these characteristics that can be interpreted as a reconfiguration and modification of networks and their stability and robustness properties. Clearly, future studies are necessary to assess the impact of such a non-pharmaceutical intervention on clinical decision-making in the treatment of epilepsy. However, our findings may add to the current discussion on the importance of the gut-brain axis in health and disease.
... In addition, in modern scientific science, the abdomen represents a crucial part of the human body. This anatomical area has been intensely investigated in the scientific literature, and it is referred to as a "second brain"-the "abdominal brain" [34,35]. The relationship between the enteric nervous system (ENS), gut microbiota and neurological diseases, including chronic pain, is receiving increasing attention from researchers. ...
Background: Pain related to Temporomandibular Disorders (TMD) is severe, negatively affecting patients' quality of life, and often resistant to conventional treatments. Abdominal Acupuncture (AA) is known to be particularly effective for pain, especially chronic and musculoskeletal pain, but it is still poorly studied and never investigated in TMD patients.
Objectives: To analyze the efficacy of AA for the treatment of patients with subacute and chronic pain related to TMD and non-responding to previous conventional therapies (occlusal splint, medications, physical therapy).
Methods: Twenty-eight patients, 24 F and four M (mean age 49.36 years), were recruited from January 2019-February 2021. All patients underwent AA treatment: two sessions per week for four weeks, for a total of eight sessions. At the beginning of therapy (T0) and at the end of the cycle (T1) the following data were evaluated: maximum mouth opening (MMO); cranio-facial pain related to TMD (verbal numeric scale, VNS); pain interference with normal activities and quality of life of patients (Brief Pain Inventory, BPI); oral functioning (Oral Behavior Checklist, OBC); impression of treatment effectiveness (Patients' Global Impression of Improvement, PGI-I Scale). Statistical comparison of data before and after the AA treatment was performed by Wilcoxon's signed-rank test (significance level p < 0.05).
Results: The MMO values were significantly improved after one cycle of AA (p =
0.0002). In addition, TMD-related pain had a statistically significant decline following AA treatment (all p < 0.001). Patients’ general activity and quality of life (BPI) were described as improved following a course of AA, with statistically significant values for all aspects considered (all p < 0.05).
Conclusion: Abdominal acupuncture resulted in effective treatment of subacute/chronicresistant pain related to TMD, capable of improving mandibular function and facial pain, and reduced the interference of pain affecting patients' quality of life.
... It also contains glia-like supportive cells, and together contains nearly 100 million neurons, similar to the number of neurons in the spinal cord. 2,3 The gut-brain axis describes the bidirectional neural pathways linking cognitive and emotional centres in the brain to the neuroendocrine centres, the enteric nervous system and the immune system. 4 Emotional states, such as depression, and behavioural dispositions, ranging from hostility to psychosocial stress, can directly influence both physiological function and health outcomes in different ways; 5 one such example is the gut-brain connection. ...
The gut has been considered a digestive organ until the recent discovery of the gut – brain axis. The gut – brain axis is a connection through which the gut microbes are able to influence and control the emotions as well as the cognition of an individual through neuroimmunoendocrinological pathways. This article puts forth some of the well-established discoveries of the gut – brain axis, explaining the mechanism of action on how gut microbes modulate the formation of the enteric nervous system and the production of neurohormones and chemokines to alter the cognitive performance of the brain and the emotional balance of an individual through neural, immune and endocrine pathways. Moreover, this bidirectional axis acts as a new key to understand the mind – body connection in the future.
... Electrical signals are used by all neuronal networks that function as a brain for receiving, processing, storing and using information: the abdominal brain, the heart brain and the head brain. Coherence occurs when harmony is experienced between the physical, emotional, mental and inspirational levels of functioning (Reiter, 1977;McCraty, Atkinson, Tiller, Rein & Watkins, 1995;McMillin et al., 1999;Zohar & Marshall, 2001). This is also known as 'being in the flow', which promotes peak performance. ...
... In terms of brain chemistry, withdrawal reactions are located in the right frontal The lower elixir field, the center of transformation in Daoist practice, in Western physiology matches the abdominal brain, the seat of inherent, spontaneous intelligence, in the vernacular described as gut feelings or intuition. A popular medical idea in the late nineteenth century (see Bedell 1885), it has re-emerged in recent research as the seat of an active enteric nervous system that governs the well-being of the person (McMillin et al. 1999). Its activation is best known from Zen Buddhist practice, which requires a tightly held upright posture as well as conscious breathing and control over the diaphragm (Sekida 1975, 84). ...
Every man, woman, and child holds the possibility of physical perfection: it rests with each of us to attain it by personal understanding and effort." —F. M. Alexander Daoist practice proceeds on three levels: healing, longevity, and immortality, three different stages of perfection and empowerment along the same continuum of the human body, which is consists of qi in various degrees of subtlety and refinement. Qi is bioenergetic potency that causes things to live, grow, develop, and decline. People as much as the planet are originally equipped with prenatal or primordial qi that connects them to the greater universe, but they also work with postnatal or interactive qi which can enhance or diminish their primordial energy. As people interact with the world on the basis of passions and desires, sensory/sexual exchanges, and intellectual distinctions, they begin to lose their primordial qi. Once they have lost a certain amount, they decline, experience sickness, and eventually die. Healing, then, is the recovery of essence and replenishing of qi with medical means such as medicines, herbal formulas, acupuncture, massage, and so on, from a level of severe deficiency to a more harmonious state. Longevity, next, comes in as and when people have become aware of their situation and decide to heal themselves. Attaining a basic state of good health, they proceed to increase their primordial qi to and even above the level they had at birth. To do so, they live an overall moderate and natural lifestyle, follow specific diets, supplement their food with herbs and minerals, and undertake breath control, healing exercises, self-massages, sexual hygiene, and meditations. These practices ensure not only that people attain their natural life expectancy but lead to increased old age and vigor.
... 7 In the West over a hundred years ago, osteopaths described mutually reciprocal influences of brain and abdomen and the concept of the "abdominal brain". 9 Anatomically, an estimated 100 million neurons are located in the abdominal viscera. ...
A number of well-known acupuncture microsystems are used in contemporary clinical practice including the auricular acupuncture system of Nogier, the scalp acupuncture system of Yamamoto, and the hand acupuncture system of Yoo. These microsystems are based on the discovery of a somatotopic relationship of a particular body area to functional areas of the cerebral cortex. Zhiyun Bo introduced an abdominal acupuncture microsystem in 1991 and published the first text on this microsystem in 1999. Accurate localization of acupuncture points on any of these microsystems in clinical practice can be difficult. A novel technique to rapidly and accurately localize microsystem acupoints via stimulation of those points with low-level laser energy is described herein. This technique can be used with any acupuncture microsystem and when applied to the abdominal acupuncture microsystem, is termed the New Abdominal Acupuncture (NAAP). NAAP produces rapid clinical improvements with durable results; clinical examples of this technique are presented.
... Although peripheral pathways mediate the actual vomiting process (Lang, 1999;McMillin, Richards, Mein and Nelson, 1999), nausea and vomiting in migraine (Dahlof and Hargreaves, 1998) and motion sickness (Takeda et al., 2001;Cass, Ankerstjerne, Yetiser, Furman, Balaban, and Aydogan, 1997) are assumed to originate within the central nervous system. In support of the central generation of nausea in motion sickness, Levine, Chillas, Stern and Knox (2000) found that while gastric tachyarrythmia resolved following administration of 5-HT receptor antagonist antiemetics during optokinetic stimulation, nausea (and other symptoms of motion sickness) still developed. ...
The brainstem is a structurally complex region, containing numerous ascending and descending fibres that converge on centres that regulate bodily functions essential to life. Afferent input from the cranial tissues and the special senses is processed, in part, in brainstem nuclei. In addition, brainstem centres modulate the flow of pain messages and other forms of sensory information to higher regions of the brain, and influence the general excitability of these cortical regions. Thus, disruptions in brainstem processing might evoke a complex range of unpleasant symptoms, vegetative changes and neurovascular disturbances and that, together, form attacks of migraine. Migraine is linked with various co-morbid conditions, the most prominent being motion sickness. Symptoms such as nausea, dizziness and headache are common to motion sickness and migraine; moreover, migraine sufferers have a heightened vulnerability to motion sickness. As both maladies involve reflexes that relay in the brainstem, symptoms may share the same neural circuitry. In consequence, subclinical interictal persistence of disturbances in these brainstem pathways could not only increase vulnerability to recurrent attacks of migraine but also increase susceptibility to motion sickness. Mechanisms that mediate symptoms of motion sickness and migraine are explored in this paper. The physiology of motion sickness and migraine is discussed, and neurotransmitters that may be involved in the manifestation of symptoms are reviewed. Recent findings have shed light on the relationship between migraine and motion sickness, and provide insights into the generation of migraine attacks.
... Neuropeptide and neurotransmitters produced in the gastrointestinal (GI) tract regulate GI motility, blood flow, secretion and absorption. 8,9 The enteric nervous system and central nervous system have direct effects on each other. For example, stress is known to aggravate the GI tract by stimulating the release of neuropeptides and neurotransmitters, triggering various GI responses. ...
In functional gastrointestinal (GI) disorders including functional dyspepsia (FD) and irritable bowel syndrome (IBS), there might be no small extent of contributions of psychosomatic factors. As a therapy for IBS patients, the effectiveness of antidepressants has been reported.
In this study, we evaluated the efficacy of H2-receptor antagonist (famotidine) and 5-HT4 receptor agonist (mosapride citrate). In addition, the effect of antidepressants was assessed as the second-step therapy.
Patients complaining upper GI symptoms were diagnosed as FD excluding organic diseases. Randomized patients received 20 mg/day of famotidine or 15 mg/day of mosapride citrate for 4 weeks and the efficacy was compared between the two groups based on a 10-point visual analogue scale. When symptoms were not relieved (score improvement 0-2 points), patients received amitriptyline (30 mg/day) or no medication for 4 weeks randomly. Patients who had depression in psychological test (SDS) were omitted.
As the first-step therapy, both famotidine and mosapride showed beneficial effects regardless of FD subtypes, age and gender. The efficacy of these two drugs in relieving FD symptoms was not significantly different. In patients who failed in the first-step therapy, amitriptyline showed beneficial effects.
These findings might be clinically important in view of the efficient relief of symptoms in FD patients.
... The ENS acts as a local minibrain producing the same neuropeptides and neurotransmitters found in the central nervous system (CNS) [24] . These act locally to regulate gastrointestinal motility, blood flow, secretions, and absorption [25]. The CNS, in turn, has its own effects on the ENS. ...
Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique.
22 children, aged 5-18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with < or = 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline.
At baseline the children who received guided imagery had more days of pain during the preceding month (23 vs. 14 days, P = 0.04). There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one (67% vs. 21%, P = 0.05), and two (82% vs. 45%, P < 0.01) months and significantly greater decrease in days with missed activities at one (85% vs. 15%, P = 0.02) and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of < or = 4 day of pain each month and no missed activities (RR = 7.3, 95%CI [1.1,48.6]) than children who learned only the breathing exercises.
The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP.
Children and adolescents commonly experience physical symptoms that are not readily explained by identifiable medical illness or tissue pathology. Such symptoms can be transient and benign, or they can be persistent, severe, and disabling. Whether or not the symptoms are explained by a medical problem, some children have great difficulty coping with them. Among children that appear more distressed or disabled by physical symptoms than expected, a diagnosis of Somatoform Disorder can be made. There are presently seven identified Somatoform Disorders that can be applied to children, despite the lack of empirical data regarding the appropriateness of such diagnoses in this age group. A large and growing literature on pediatric chronic pain has informed the conceptualization, assessment, and treatment of childhood somatoform disorders. Most clear regarding the current understanding of chronic somatic symptoms is their multifaceted etiological nature and the necessity of interventions to address biological, psychological, and social precipitating and maintaining factors. Important areas of assessment include the nature of the physical symptoms themselves, including their location, duration, quality, variability, and intensity; the social, emotional, physical, cognitive, and academic functioning of the symptomatic child; and, family factors such as parenting style, response to child symptoms, and psychopathology. Frequently employed treatment strategies include medications, individual and/or family cognitive behavioral interventions, and body-based therapies. Ideally, these assessment and treatment methodologies are collaboratively implemented within a biopsychosocial framework by medical and psychological professionals who are familiar with the related research evidence base.
This book allows readers to extend their practice by increasing their understanding of acupuncture and indicating where and how it will benefit their patients. Unlike many obscure acupuncture texts, this book makes the assimilation of knowledge of Chinese language and medical philosophies easy.
A variety of eating problems, especially problems with food selectivity, have been reported in children with autism spectrum disorders (ASDs). A few studies have examined children with and without ASDs and compared eating problems found in a group of children. Other research has examined possible etiological factors that lead to eating problems among children with ASDs. This review discusses these areas of research. While the treatment of eating problems among children with ASDs can present a clinical challenge to providers, there is a growing literature detailing effective interventions for the eating problems in this population. Methods of assessment as well as details of interventions that have been found to effectively treat eating problems among children with ASDs are described.
Sebbene il sistema nervoso enterico (“enteric nervous system”, ENS)
svolga un ruolo cruciale nella patogenesi della Scrapie ovina, non
esistono tuttavia in letteratura dati sulle popolazioni cellulari
progressivamente coinvolte nel corso dell’infezione, né sugli eventuali
danni morfo-funzionali da esse subiti.
Il presente studio è stato condotto sui plessi mienterici e sottomucosi
dell’ileo di 46 pecore di razza Sarda, recanti diversi polimorfismi del
gene Prnp (ARQ/ARQ, ARQ/AHQ, ARQ/ARR, ARR/ARR). I suddetti
animali, infettati per os all’età di 8 mesi con un ceppo di Scrapie
precedentemente caratterizzato nel topo, sono stati sacrificati mediante
eutanasia a determinati intervalli di tempo post-infezione (p.i.). E’ stata
quindi valutata, tramite immunoistochimica ed immunofluorescenza
indiretta su sezioni tissutali e su preparati “wholemount”,
l’immunoreattività (IR) nei confronti della PrPSc, del “marker” panneuronale
Hu C/D, dell’ossido-nitrico sintetasi (nNOS), della calbindina
(CALB) e della proteina fibrillare acida gliale (GFAP).
In 8 pecore con genotipo ARQ/ARQ, clinicamente sane e sacrificate a
12-24 mesi p.i., nonché in 5 ovini clinicamente affetti (2 con genotipo
ARQ/ARQ, 3 con genotipo ARQ/AHQ), questi ultimi sacrificati
rispettivamente a 24, 36 e 40 mesi p.i., le indagini immunoistochimiche
hanno consentito di dimostrare la presenza di PrPSc a livello sia
dell’encefalo (obex), sia dell’ENS, in particolar modo nei plessi
mienterici. In tali distretti il deposito della PrPSc risultava pienamente
compatibile con un interessamento delle cellule enterogliali (“enteroglial
cells”, EGCs), mentre occasionalmente si notava un contestuale
coinvolgimento della componente neuronale ivi residente.
In conclusione, i dati della presente indagine consentono di ipotizzare un
verosimile coinvolgimento delle EGCs e dei neuroni residenti a livello
dei plessi dell’ENS nella patogenesi della Scrapie sperimentale
realizzata per os in ovini di razza Sarda. The enteric nervous system (ENS) is believed to play a key role in the
pathogenesis of sheep Scrapie infection, although no information exists
on the ENS cytotypes which are progressively involved, nor on the
morpho-functional damage of such cells in the time course of infection.
We investigated the ileal myenteric (MPs) and submucosal plexuses
(SMPs) of 46 Sarda breed sheep carrying different PrP genotypes
(ARQ/ARQ, ARQ/AHQ, ARQ/ARR, ARR/ARR), which had been
orally dosed with Scrapie at 8 months of age and euthanized at definite
time intervals post-infection (p.i.). PrPSc immunoreactivity (IR), along
with pan-neuronal marker Hu C/D, nitric oxide synthase (nNOS),
calbindin (CALB) and glial fibrillary acidic protein (GFAP)-IR, were
evaluated by means of immunohistochemistry (IHC) and indirect
immunofluorescence (IF) on paraffin-embedded sections and
wholemount preparations.
Eight clinically-healthy ARQ/ARQ sheep euthanized at 12-24 months
p.i., along with 2 ARQ/ARQ (euthanized at 24 months p.i.) and 3
ARQ/AHQ (euthanized at 36 and 40 months p.i., respectively) clinicallyaffected
sheep, showed IHC evidence of PrPSc in both their brain (obex)
and ENS, especially in MPs. PrPSc deposition was fully compatible with
an involvement of enteroglial cells (EGCs) and, occasionally, also with
an involvement of neurons residing within ileal ENS plexuses.
In conclusion, EGCs and neurons residing within ileal ENS plexuses
may be likely involved in the pathogenesis of oral experimental Scrapie
infection in Sarda breed sheep.
To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children.
Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results.
Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance.
Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.
Secretin is used in the United States for diagnosis of pancreatic gastrointestinal (GI) dysfunction and disease. Repeated therapeutic use has not been approved. Widespread interest in secretin as a treatment for autism followed media reports of behavioral improvements in an autistic child who received the hormone during a GI diagnostic procedure. International demand for secretin soared in the absence of experimental evidence of its efficacy for autism. This review presents a brief history of secretin's rise to popularity and summarizes research on secretin as a treatment for autism. Seventeen studies are reviewed comparing the effects of secretin forms, dosage levels, and dosing intervals on outcome measures with approximately 600 children. Twelve of 13 placebo-controlled studies failed to demonstrate the differential efficacy of secretin. Implications for advocating treatment in the absence of empirical evidence are discussed.
Interest in the gastrointestinal (GI) factors of autistic disorder (autism) has developed from descriptions of symptoms such as constipation and diarrhea in autistic children and advanced towards more detailed studies of GI histopathology and treatment modalities. This review attempts to critically and comprehensively analyze the literature as it applies to all aspects of GI factors in autism, including discussion of symptoms, pathology, nutrition, and treatment. While much literature is available on this topic, a dearth of rigorous study was found to validate GI factors specific to children with autism.
60 migraine patients completed elimination diets after a 5-day period of withdrawal from their normal diet. 52 (87%) of these patients had been using oral contraceptive steroids, tobacco, and/or ergotamine for an average of 3 years, 22 years, and 7.4 years respectively. The commonest foods causing reactions were wheat (78%), orange (65%), eggs (45%), tea and coffee (40% each), chocolate and milk (37%) each), beef (35%), and corn, cane sugar, and yeast (33% each). When an average of ten common foods were avoided there was a dramatic fall in the number of headaches per month, 85% of patients becoming headache-free. The 25% of patients with hypertension became normotensive. Chemicals in the home environment can make this testing difficult for outpatients. Both immunological and non-immunological mechanisms may play a part in the pathogenesis of migraine caused by food intolerance.
According to our earlier results, non-painful, weak afferent visceral signals may exert a steady influence on brain processes,
including cognitive functions. In the present series colonic impulses of irritable bowel syndrome (IBS) subjects served as
a model of chronic impact from the gut. Hemispheric preference, as well as cognitive style of information processing served
as indicators of covert changes in brain functions. In twentyone IBS patients and in ten control subjects of both sexes, the
thresholds of minimal colonic distension sensitivity has been measured following the determination of hemispheric preference
and of advantage in verbal or spatial information processing of the subjects. In IBS patients distension thresholds proved
to be higher in verbals than in spatials, whereas in healthy controls the relationship of colonic thresholds and verbal versus,
spatial advantage was reversed. Among the normal controls with left hemisphere preference a significantly higher distension
threshold has been observed than in those with right hemisphere preference, whereas in the IBS group such threshold-differences
were not observable.
Persons with the irritable bowel syndrome (IBS) have a significantly higher prevalence of globus and migraine-like headache than age-matched control subjects. On the other hand, persons with organic disease of the esophagus or colon may have a reduced prevalence of functional symptoms involving the opposite end of the gastrointestinal tract. The dispersed pattern of symptoms in IBS suggests that some agent, such as a hormone, may be acting systemically.
The authors present the case report of a child with abdominal epilepsy who had suffered from abdominal pain for several months under the label of psychogenic pain. The important historical clues were pallor and cold sweating during the paroxysm, followed by lethargy and prolonged sleep. An abnormal electroencephalogram and a remarkable response to anticovulsants confirmed the diagnosis. This condition must be considered in a child with undiagnosed recurrent abdominal pain.
Sixteen children with recurrent abdominal pain (or: “recurrent syndrome”), regarded as migraine equivalent in childhood, were submitted to the 51-Cr ED T.A. gut permeability test.The results were compared with those obtained in 10 healthy young adults and in 11 control children.The gut permeability in the recurrent syndrome was significantly' higher than in healthy adults and control children (p < 0.0006): The following results were obtained: 4.83 ± 0.40 (mean ± SEM) in the children with recurrent abdominal pain, and 2.35 ± 0.24 2.51 ± 0.21 in the healthy young adults and control children, respectively.The implications of these findings as far as migraine is concerned, are discussed.
To the Editor.—
The discussion of abdominal epilepsy by Peppercorn and associates served to remind us that CNS diseases can cause severe paroxysmal abdominal pains and should be included in the differential diagnosis for such symptoms.I would remind readers, however, that symptom complexes similar to those observed with the authors' patients can be seen in acute intermittent porphyria. In such cases most of the common anticonvulsant drugs, including phenytoin (Dilantin), barbiturates, methsuximide (Celotin), mephenytoin (Mesantoin), and phensuximide (Milontin), are contraindicated because of their ability to precipitate an acute attack.¹For this reason it seems prudent to determine the level of urinary excretion of δ-aminolevulinic acid and porphobilinogens in patients thought to have abdominal epilepsy before beginning drug therapy.
Congenital birth defects, of which Hirschsprung's disease is an example, are among the most difficult of illnesses to study in the human patients who suffer from them. By the time the condition is identified in an affected individual, the process that brought it about is over and done with. It is thus impossible to study the ontogeny of birth defects, such as Hirschsprung's disease, in a fetus while the problems develop. An investigator seeking to uncover the pathogenesis of such a condition must search, like a detective, for clues left behind by the perpetrator who has fled the scene of a crime. Even the identification of genes that may have mutated, important an achievement as that is, does not, by itself, explain why the defect develops. Human life, moreover, is so precious that human subjects are terrible laboratory animals. As a result, more can often be learned about the origins of human illness by studying animal models, than by investigating the patients themselves. Invasive research, which is only possible on animals, can be used to develop a conceptual framework to devise hypotheses that can subsequently be tested for applicability to human patients. Experiments, based on these hypotheses, can be targeted to what can be confirmed or denied by diagnostic tests or by analyzing the restricted materials available from human subjects. Human biology is thus made approachable by knowledge of animal biology.
The enteric nervous system (ENS) is a quasi autonomous part of the nervous system and includes a number of neural circuits that control motor functions, local blood flow, mucosal transport and secretions, and modulates immune and endocrine functions. Although these functions operate in concert and are functionally interlinked, it is useful to consider the neural circuits involved in each separately.1 This short summary will concentrate mainly on the neural circuits involved in motor control.2 The enteric neural circuits are composed of enteric neurones arranged in networks of enteric ganglia connected by interganglionic strands. Most enteric neurones involved in motor functions are located in the myenteric plexus with some primary afferent neurones located in the submucous plexus. As in all nervous systems involved in sensory-motor control, the ENS comprises primary afferent neurones, sensitive to chemical and mechanical stimuli, interneurones and motorneurones that act on the different effector cells including smooth muscle, pacemaker cells, blood vessels, mucosal glands, and epithelia, and the distributed system of intestinal cells involved in immune responses and endocrine and paracrine functions.
The digestive tract is unique among internal organs because it is exposed to a large variety of physicochemical stimuli from the external world in the form of ingested food. As a consequence, the intestine has developed a rich repertoire of coordinated movements of its muscular apparatus to ensure the appropriate mixing and propulsion of contents during digestion, absorption, and excretion. The oro-aboral transit of the intestinal contents can be regarded as a form of adaptive locomotion that occurs over a wide range of spatial and temporal domains.3 The movements of the intestine are the result of interaction of the neural apparatus and the muscular apparatus.4
The muscular apparatus is organised in muscle layers made up of large collections of smooth muscle cells …
• Electroencephalography documented partial seizures manifested as paroxysmal vomiting in a child.
A common, and often perplexing, diagnostic challenge is the unfortunate person with recurrent abdominal pain. When a searching history, thorough physical examination, laboratory evaluation, and radiological studies are to no avail, such patients are often labeled neurotic, or advised to undergo exploratory surgery. It is in such a setting that the subject of abdominal epilepsy is occasionally raised. Since in our experience physicians know little about this rare entity, we feel a brief review is pertinent at this time.
Experimental studies in both animal and human subjects have shown that stimulation of certain areas in the brain stem, hypothalamus, and cerebral cortex can influence gastrointestinal activity and cause a variety of visceral sensations.1-5 Up to 20% of patients with convulsive disorders, particularly those with temporal lobe seizures, will experience a visceral aura such as epigastric distress, peculiar "rising sensations," nausea, vomiting, salivation, and borborygmi.4,6 Usually these symptoms are
It has long been recognized that some cases of recurrent abdominal pain in children are related to migraine, but the diagnostic criteria for abdominal migraine have not been defined. We have identified a group of children with recurrent abdominal pain who had a family history of migraine—in over half the cases in a first-degree relative—and who obtained marked relief from their symptoms from specific anti-migraine therapy. These children had a well-defined syndrome comprising episodes of midline abdominal pain of sufficient severity to interfere with normal activities and lasting for prolonged periods, frequently accompanied by pallor, headache, anorexia, nausea, and vomiting. It is proposed that these children have “abdominal migraine”.
SYNOPSIS
Sandler, Youdim and Hannington noted an inability to oxidise tyramine and phenylethylamene in dietary and non dietary migraine sufferers-l,883 female volunteers in Britain completed questionnaires detailing food intake during the 24 hours prior to spontaneous migraine attacks. Analysis of 2,313 attacks are reported. This revealed consumption of chocolate in 33%, cheese 40%, citrus fruits 21% and alcohol 23%. Fasting (5 hours day or 13 hours overnight) occurred in 67%. No dietary factors were isolated in 5%. Only 14% thought food caused their attacks and 2% blamed fasting. Sensitising factors analysed included age, time in menstrual cycle, pill taking and hysterectomy. The findings suggest that in double blind trials designed to elucidate dietary factors, one needs to consider the patient's intake during the 24 hours prior to the administration of the test capsule. A new approach to treatment is suggested with elimination of specific foods and avoidance of fasting.
As part of a larger investigation into the subject of chronic abdominal pain in children we have conducted a preliminary survey on twelve children with ages ranging between 5 and 15 years. They all presented with a history of recurrent abdominal pain for a minimum of 3 months (Apley, 1975), but some had been symptomatic for more than 8 years. All had experienced nausea and/or vomiting combined with a family history of classical migraine. In addition, pallor (Liebman, 1978) was a feature in eleven of the patients during a migrainous attack. On this basis, a clinical diagnosis of abdominal migrain was established (see Table 1).
To the Editor.—
In their article "Ab dominal Epilepsy," Peppercorn et al (240:2450, 1978) state: "the disorder rarely has been reported in older adolescents and adults." By 1952 I had already reported 28 cases of abdominal epilepsy,1 the majority of which were in adults aged 19 to 63 years, and quoted the literature wherein adults as well as children were involved1-3 (124:561, 1944; 129:1233,1945). Since then I have seen many cases, mainly in adults. The majority of such cases in children and young adolescents gravitate to pediatricians; thus, the reports of Livingston4 and others have, by now, primarily conditioned pediatricians to an awareness of the disorder.In devising the term "abdominal epilepsy," first in 1943 and 1944, it was my purpose to call attention to a syndrome of paroxysmal abdominal pain whose symptoms and etiology had not been adequately recognized as an aberrant form of epilepsy and
60 migraine patients completed elimination diets after a 5-day period of withdrawal from their normal diet. 52 (87%) of these patients had been using oral contraceptive steroids, tobacco, and/or ergotamine for an average of 3 years, 22 years, and 7.4 years respectively. The commonest foods causing reactions were wheat (78%), orange (65%), eggs (45%), tea and coffee (40% each), chocolate and milk (37%) each), beef (35%), and corn, cane sugar, and yeast (33% each). When an average of ten common foods were avoided there was a dramatic fall in the number of headaches per month, 85% of patients becoming headache-free. The 25% of patients with hypertension became normotensive. Chemicals in the home environment can make this testing difficult for outpatients. Both immunological and non-immunological mechanisms may play a part in the pathogenesis of migraine caused by food intolerance.
A controlled trial of cervical manipulation for migraine. G. B. Parker, H. Tupling and D. S. Pryor, Aust. N.Z. J. Med., 1978, 8, pp. 589–593.
The efficacy of cervical manipulation for migraine was evaluated. In a six-month trial, 85 volunteers suffering from migraine were randomly allocated to three treatment groups. One group received cervical manipulation performed by a medical practitioner or by a physiotherapist, another received cervical manipulation performed by a chiropractor, while the control group received mobilization performed by a medical practitioner or by a physiotherapist. For the whole sample, migraine symptoms were significantly reduced. No difference in outcome was found between those who received cervical manipulation, performed by chiropractor or orthodox therapist, and those who received the control treatment. Chiropractic treatment was no more effective than the other two treatments in reducing frequency, duration or induced disability of migraine attacks, but chiropractic patients did report a greater reduction in pain associated with their attacks.
Four patients, aged 17 to 47 years, had paroxysmal abdominal pain associated with symptoms suggestive of a CNS disturbance. None had a discernible primary gastrointestinal process, but each had EEG abnormalities and a striking response to anticonvulsant medication. These findings suggest that abdominal epilepsy should be considered in the differential diagnosis of unexplained paroxysmal abdominal pain.
The ketogenic diet was developed in the 1920s as a treatment for intractable childhood seizures when few antiepileptic drugs (AEDs) were available. There are still children whose seizures are refractory even to modern therapy, but use of the ketogenic diet appears to be waning. At Johns Hopkins, we continue to believe that the diet is very effective and well accepted by patients and families. To reevaluate our opinion of the efficacy and acceptability of this form of therapy in patients cared for in the 1980s with the newer AEDs, we analyzed the records of 58 consecutive patients who had been started on the diet. Before using the diet, 80% of the patients had multiple seizure types and 88% were treated with multiple AEDs; these children were among our most intractable patients. Despite this, seizure control improved in 67% of patients with the ketogenic diet, and actuarial analysis indicated that 75% of these improved patients continued the diet for at least 18 months. Sixty-four percent had AEDs reduced, 36% became more alert, and 23% had improved behavior. The improvement in these patients with intractable seizures and the length of time that families maintained the regimen indicate that the ketogenic diet continues to have a very useful therapeutic role in selected patients and their families.
To determine the prevalence of symptoms compatible with a clinical diagnosis of irritable bowel syndrome in the general population.
Validated postal questionnaire sent to 2280 subjects randomly selected in 10 year age bands from the lists of eight general practitioners. The Manning criteria were used to define irritable bowel syndrome.
Urban population in Southampton and mixed urban-rural population in Andover, Hampshire.
A response of 71% yielded 1620 questionnaires for analysis, of which 412 (25%) reported more than six episodes of abdominal pain in the preceding year, with 350 (22%) reporting symptoms consistent with the diagnosis of irritable bowel syndrome. The male: female ratio was 1:1.38. More subjects with irritable bowel syndrome had constipation and diarrhoea and 35% with the syndrome reported rectal bleeding compared with an overall prevalence of 20%. Other symptoms and conditions including heartburn, dyspepsia, flushing, palpitations, migraine, and urinary symptoms were significantly more common in the group with irritable bowel syndrome. Abdominal pain in childhood was more common in the subjects with irritable bowel syndrome (12%) than without (3%). One third of the group with irritable bowel syndrome had sought medical advice during the study period (male:female ratio 1:1.21); consultation behaviour was influenced by age and the presence of associated symptoms, varied considerably among patients registered with different general practitioners, and was poorly correlated with symptom severity.
Symptoms consistent with a diagnosis of irritable bowel syndrome are present in almost one quarter of the general population and tend to be associated with a number of other complaints and conditions, some of which may reflect smooth muscle dysfunction.
The criteria now used in an attempt to distinguish irritable bowel syndrome from organic gastrointestinal disease rely almost entirely on symptoms of colonic origin. 'Non-colonic' symptoms, however, arising either from elsewhere in the gut or of a more general nature, are common in irritable bowel syndrome and may have even better diagnostic potential. The prevalence of these non-colonic features was assessed in 107 patients with the irritable bowel syndrome and 295 subjects with other gut disorders. Gastrointestinal type non-colonic symptoms are useful in differentiating irritable bowel syndrome from inflammatory bowel disease but, with the exception of early satiety, are not helpful when there is gastro-oesophageal or biliary disease. More general 'non-colonic' features, such as lethargy and backache, are much commoner in irritable bowel syndrome than in all the organic gastrointestinal diseases studied and have good discriminant function. Multiple logistic regression analysis identified certain features that had a particularly significant independent risk for irritable bowel syndrome. Those were lethargy (relative risk 6.7), incomplete evacuation (RR 5.2), age under 40 (RR 2.1), backache (RR 2.0), early satiety (RR 1.8), and frequency of micturition (RR 1.8). These relative risks can be multiplied together to give an overall risk when more than one of these features is present in a patient. Until a diagnostic test is available more confident diagnosis of irritable bowel syndrome can be achieved by identifying symptoms that have good discriminant function. The results of this study indicate that the non-colonic features of irritable bowel syndrome may be especially valuable in this respect.
Psychiatric illnesses such as mood, anxiety, and somatization disorders share many common features with irritable bowel syndrome. The authors review recent developments in the definition of irritable bowel syndrome and its relationship to psychiatric illness, discuss the diagnostic validity of irritable bowel syndrome from several perspectives, and offer a pathophysiological model of irritable bowel syndrome that integrates many of the biological and psychosocial findings of earlier studies. Psychiatric evaluation appears to be an important factor in the diagnosis and treatment of patients with irritable bowel syndrome.
SYNOPSIS
Abdominal migraine is a common childhood migraine equivalent, for which diagnostic criteria have not been defined. As in other children with migraine equivalents this leads to difficulties in diagnosis and determination of prevalence. By recording the fast wave activity (beta rhythmn) in the visual evoked response (VER) to red and white flash, the pattern stimulation, 27 out of 28 children with clinically diagnosed abdominal migraine revealed significant differences compared with normal controls, outside the attack phase. Comparisons with children diagnosed as migraine with or without aura revealed, from the VER findings of higher amplitude fast wave activity and the presence of paroxysmal sharp wave activity, that abdominal migraine appears to be a specific form of childhood migraine. We found that both clinically and electrophysiologically, abdominal migraine changes with age; older children exhibiting a shorter duration of abdominal pain during attacks, and less evidence of sharp wave activity in the VER.
The association between headache and gastrointestinal symptoms is typical of migraine and useful for diagnosis. Diagnosis is difficult when migraine consists only of gastrointestinal symptoms without headache. In such a situation differential diagnosis is very widespread, sometimes implying diagnostic and therapeutic delays with unpleasant consequences for the patient and embarrassment for the physician. We report on the troubled clinical history of three adults with abdominal equivalents.
A complex network of neurotransmission systems underlies the control of the cerebral circulation. Classical neurotransmitters, vasoactive peptides and receptors have been found in cerebral arteries. Central and peripheral structures are also probably involved in the neurogenic control of the cerebral circulation. Vascular and neurotransmission changes reported in vascular headaches suggest that an alteration of the neurogenic control of the brain circulation may be implicated in vascular headaches. In particular, locus coeruleus, which may control the intracerebral adrenergic pathway, can induce vascular changes similar to those of migraine. Moreover, the trigeminal ganglion, which may induce the release of substance P, can change the extracranial and intracranial vasodilator activity. The vascular theory of migraine, proposed by Wolff, is re-evaluated on the grounds of a possible mediation of the vascular responses by neurotransmitters. It is hypothesized that a deficient modulation by enkephalins may cause alterations of locus coeruleus and/or trigeminal ganglion. The problem of pain in vascular headaches is also considered: whether it is of vascular origin or whether it is due to a dysfunction of the central nociceptive pathway. Knowledge of the neurogenic control of the cerebral circulation may be useful in understanding some pathogenetic mechanisms of vascular headaches.
Sixteen children with recurrent abdominal pain (or: "recurrent syndrome"), regarded as migraine equivalent in childhood, were submitted to the 51-Cr EDTA gut permeability test. The results were compared with those obtained in 10 healthy young adults and in 11 control children. The gut permeability in the recurrent syndrome was significantly higher than in healthy adults and control children (p less than 0.0006): The following results were obtained: 4.83 +/- 0.40 (mean +/- SEM) in the children with recurrent abdominal pain, and 2.35 +/- 0.24 2.51 +/- 0.21 in the healthy young adults and control children, respectively. The implications of these findings as far as migraine is concerned, are discussed.
This report reviews the gastrointestinal and central nervous system complaints and clinical course in 10 adult patients with abdominal epilepsy. Abdominal symptoms included paroxysmal pain, nausea, bloating, and diarrhea. Nervous system manifestations included dizziness, headache, confusion, syncope and transient blindness. Each patient had specific electroencephalographic abnormalities of a temporal lobe seizure disorder. Anti-convulsant therapy has resulted in the sustained abolition of symptoms in each case.
Clinical observations and studies support the role of food in causing migraine and sinus headache. Diagnosis of food allergy is based on a diet log, diet trial, and prospective food challenges as indicated. In most cases, patients with food-provoked headache can obtain relief by avoiding a few selected, commonly eaten foods. Benefits of an avoidance diet include the need for fewer medications.
In 100 patients with irritable bowel syndrome a wide variety of non-gastrointestinal symptoms were significantly more common than in a group of 100 age, sex, and social class matched controls. Nocturia, frequency and urgency of micturition, incomplete bladder emptying, back pain, an unpleasant taste in the mouth, a constant feeling of tiredness and in women dyspareunia were particularly prominent (p less than 0.001). With reference to non-colonic gastrointestinal symptoms nausea, vomiting, dysphagia and early satiety were very common (p less than 0.0001). This symptom diversity was observed irrespective of whether the patient had a psychiatric disorder or not. Patients smoked more than controls (p = 0.02) drank more caffeine containing drinks (p = 0.03) and 26% had taken at least one week off work in the previous 12 months. Thirty three per cent of patients had a family history of irritable bowel syndrome. Cognisance of these diverse symptoms may prevent referral to the wrong medical specialty and inappropriate investigation. They may also be indicative of a much more diffuse disorder of smooth muscle than has previously been appreciated.
Diet has been implicated as a source of migraine since antiquity. Now, diet is thought of as one of many factors that can trigger migraine. Improved understanding of the migraine process and an attempt to delineate the most common causes of diet-precipitated migraine have resulted in a more rational treatment strategy. We recognize that a small group of patients will have migraine after ingesting certain foods with vasoactive properties or by missing a meal; thus, we suggest a nutritional course to limit this influence. The role of allergy in migraine is not yet determined and remains controversial.
A diagnostic procedure during a nutritionally supported fast week followed by conventional food sensitivity management achieved major improvement for 80% of a migraine panel. This procedure gave a reliable (0.8 correlation coefficient) prognosis on the substantial value of this approach for selection of the treatment of migraine. The study gave two lines of evidence which indicate that migraine has an etiology of food sensitivity.
Foods as a cause for migraine attacks were evaluated in 43 adults with recurrent migraine. Skin testing, elimination diets, double-blind challenges, and measurements of plasma histamine were performed. Thirteen subjects experienced 66% or greater reduction in headache frequency during a diet trial. Six subjects became headache free. Eleven of 16 skin test-positive patients responded to diet manipulation, while only two of 27 skin test-negatives did (P less than .005). Seven subjects agreed to double-blind challenges. In five of seven, at least one food provoked migraine. Placebo challenges did not provoke migraine. In three subjects, plasma histamine rose during migraine provoking challenges. The relationship between food ingestion and migraine is based in part on allergic mechanism. Tests for IgE-specific food allergy appear helpful in selecting patients likely to benefit from diet therapy.
To the Editor.—
A letter about abdominal epilepsy (222:1426,1972), a survey of migraine and its equivalents (222:1399, 1972), and cited papers on the subjects fail to mention a disorder with which they may be confused. A diagnosis of childhood abdominal epilepsy seems proper when recurrent abdominalgia lasts seconds or minutes and is accompanied by disturbance of awareness or responsiveness or by grand or petit mal seizures and electroencephalographic changes. These usually are controlled by treatment with diphenylhydantoin. Otherwise, some included cases differ. Febrile episodes lasted several days and recurred about weekly, biweekly, monthly, or irregularly for decades. Combinations of abdominalgia, stethalgia, or arthralgia with leukocytosis occurred. Electroencephalographic changes occasionally were abnormal; there were no epileptiform seizures and therapy had no effect. Such features characterize periodic polyserositis (known also as familial Mediterranean fever). It affects chiefly Jews, Armenians, and Arabs.1 Correct diagnosis would clarify nosology, obviate unnecessary therapy, and avoid
The concept of abdominal epilepsy is considered and the criteria of diagnosis are established. Etiology, relationship with age, incidence, clinical state, treatment and prognosis are illustrated and discussed. Characteristic electroencephalograms of abdominal epilepsy, spike and wave complexes, paroxysmal slow dysrhythmia and 14 and 6 c/s positive spikes are indicated. (Journal received: 6 Feb. 1975)
The syndrome of abdominal-visceral epilepsy is reviewed and reappraised. It is concluded that the syndrome does exist. Criteria for its diagnosis are emphasized with special reference being made to associated alteration of awareness. The diagnosis should be made only on positive rather than negative grounds. The rigid criteria used for the diagnosis of other forms of epilepsy should also apply in this condition. These criteria include adequate historical data regarding paroxysmal pain, alteration of awareness, postictal symptoms, electroencephalographic abnormalities, and good response to anticonvulsant medication.
Foods which provoked migraine in 9 patients with severe migraine refractory to drug therapy were identified. The patients were then given either sodium cromoglycate or placebo orally in a double-blind manner, with foods previously identified as provocants. Sodium cromoglycate exerted a protective effect, thus confirming that it can prevent a hypersensitivity mechanism as well as the symptoms of migraine. Immune complexes were not produced in those patients who were protected by sodium cromoglycate. These observations confirm that a food-allergic reaction is the cause of migraine in this group of patients.